New Mexico Administrative Code

The MCO may involuntarily terminate a member from the PCS/CDirected or the SDCB approach under any of the following circumstances. A. The member, the member's authorized representative or his or her EOR refuses to follow NMAC rules, the MAD MCO policy manual, or his or her MCO po…

A. The MCO, together with the other MCOs, shall contract with a vendor to implement an EVV system in accordance with the federal Twenty First Century Cures Act. B. The MCO shall maintain an EVV system capable of leveraging up-to-date technology as it emerges to improve functional…

The New Mexico medicaid program and other health care programs are administered pursuant to regulations promulgated by the federal department of health and human services under Title XIX of the Social Security Act as amended or by state statute. See Section 27-1-12 et seq., NMSA1…

Permanent.

March 1, 2017, unless a later date is cited at the end of a section.

The objective of this rule is to provide instructions for the service portion of the New Mexico medical assistance division (MAD) programs.

A. Agency based community benefit (ABCB): The community benefit (CB) services offered to a member who does not wish to self-direct his or her CB services. B. ABCB care plan: For a member who is participating in the ABCB approach, the care plan outlines the specific community bene…

A MCO member, meeting a specific LOC, can select the approach to receiving his or her community benefit services. The MCO offers two approaches to the delivery of these services: agency based (ABCB) or self-directed (SDCB). The MCO shall use the nursing facility (NF) LOC criteria…

New Mexico Health Care Authority.

A member may earn reward credits when engaging in healthy behaviors included in the member rewards program. Reward credits are determined for specific member healthy behaviors. Details on the requirements to earn a healthy behavior reward credit are made available to a member on …

This rule applies to the general public.

The New Mexico medicaid program and other health care programs are administered pursuant to regulations promulgated by the federal department of health and human services under Title XIX of the Social Security Act as amended or by state statute. See NMSA 1978, Section 27-1-12 et …

Permanent.

January 1, 2014, unless a later date is cited at the end of a section.

The objective of this rule is to provide instructions for the service portion of the New Mexico medical assistance programs.

[RESERVED]

A member of a HSD contracted managed care organization (MCO) is eligible to participate in the managed care member rewards program. A. For a native American member who elects to opt out of receiving medical assistance division (MAD) services through a HSD contracted MCO, and reta…

New Mexico Health Care Authority.

A. When a MAD benefit has a co-payment assigned for a MAP category of eligibility, the eligible recipient will at the time of service make payment or make arrangements with the provider for payment at a later date. B. A member shares the responsibility to track his or her co-paym…

Medicaid co-payment amounts and the application of co-payments are determined by MAD. See 42 CFR 447.56, limitations on premiums and cost sharing, and 8.302.2 NMAC.

This rule applies to the general public.

The New Mexico medicaid program and other health care programs are administered pursuant to regulations promulgated by the federal department of health and human services under Title XIX of the Social Security Act as amended or by state statute. See Section 27-1-12 et seq., NMSA …

Permanent.

October 1, 2017, unless a later date is cited at the end of a section.

The objective of this rule is to provide instructions for the service portion of the New Mexico medical assistance programs (MAP).

Co-payment: A co-payment is a fixed dollar amount that a medicaid recipient must pay directly to a provider for a service, visit or item. A co-payment is to be paid at the time of service or receipt of the item.

The medical assistance division (MAD) imposes co-payment provisions on certain members, certain categories of eligibility and on certain services. The member's HSD contracted managed care organization (MCO) is required to impose co-payments as directed by MAD at 8.302.2 NMAC and …

New Mexico Health Care Authority.

A. Upon a provider contracting with the MCO, the MCO shall provide at no cost a written description of its provider appeal policies and procedures and instructions on how to act as a member's authorized provider to the provider. The MCO will update in writing each of its provider…

A. Upon a member's enrollment: (1) the MCO shall provide to the member and his or her authorized representative at no cost a written description of its member grievance and member expedited and standard appeal system and member expedited appeal system procedures and processes; (2…

A. The MCO shall provide to its member or his or her authorized representative reasonable assistance in completing grievance forms and completing procedural steps, including but not limited to: (1) providing interpreter services; and (2) providing toll-free numbers that have adeq…

The MCO shall establish and maintain an expedited review process for a MCO expedited member appeal when the MCO, the member or his or her authorized representative or authorized provider believes that allowing the time for a standard member appeal resolution could seriously jeopa…

A. A member or his or her authorized representative or the authorized provider in accordance with the member's MCO procedures has the right to request within 60 calendar days after the mailing of the MCO's notice of action a MCO standard member appeal orally and in writing. When …

A member or his or her authorized representative or authorized provider requesting a MCO expedited or standard member appeal of an adverse action may request that the disputed current benefit continue during the MCO expedited or standard member appeal process. However, if the dat…

A. The MCO shall provide the member or his or her authorized representative and the provider (regardless if the provider was not the one requesting the MCO member appeal) with its MCO expedited or standard member appeal final decision within the required time frames and provide s…

This rule applies to the general public.

The New Mexico medicaid program and other health care programs are administered pursuant to regulations promulgated by the federal department of health and human services under Title XIX of the Social Security Act as amended or by state statute. See Sections 27-2-12 et seq., NMSA…

Permanent.

May 1, 2018 unless a later date is cited at the end of a section.

The objective of this rule is to provide instructions for the service portion of the New Mexico medical assistance division programs.

A. "Administrative law judge (ALJ)" means the hearing officer appointed by the HSD fair hearings bureau (FHB) to oversee the claimant's administrative hearing process, to produce an evidentiary record and render a recommendation to the medical assistance division (MAD) director. …

A. Upon a provider contracting with the MCO, the MCO shall provide at no cost a written description of its provider grievance policies and procedures to the provider. The MCO will notify each of its providers in writing of any changes to these policies and procedures. The descrip…

New Mexico Health Care Authority.

The MCO shall ensure that each member is assigned a primary care provider (PCP), except a member that is dually eligible for medicare and medicaid (dual eligible). The PCP shall be a provider identified in Subsection A below, participating in the MCO's network who will assume the…

The MCO shall establish and follow protocols to ensure the accessibility, availability and referral to health care providers for each medically necessary service to its members. The MCO shall provide access to the full array of covered services within the benefit package. If a se…

The MCO shall ensure that there are a sufficient number of PCPs and dentists available to members to allow members a reasonable choice, and ensure that there are a sufficient number of behavioral health providers, based on the least restrictive, medically necessary needs of its m…